In the wake of the ‘Brandon’ review, HSE management provided assurances that adult safeguarding was being resourced but internal correspondences present a different picture. Catherine Reilly reports on ongoing resource and legislative deficits in the area
In December, the HSE released part of an external review into the case of ‘Brandon’, a man with an intellectual disability who sexually assaulted and abused fellow residents at a HSE residential facility in Co Donegal.
It outlined prolonged sexual abuse of residents despite the knowledge of management and staff. One of the notable findings was that the HSE had “on occasions disregarded the advice and guidance” offered by the regional adult safeguarding and protection team (SPT) in terms of “how serious safeguarding concerns should be dealt with”.
The nine regional SPTs were set up under a 2014 HSE adult safeguarding policy in social care but operate without any primary adult safeguarding legislation. The SPTs receive safeguarding concerns (‘preliminary screenings’) and safeguarding plans from HSE and HSE-funded disability and older persons services for specialist review and also directly manage cases in the community
While the safeguarding teams did not exist for most of the period under review in the Brandon case (2003-2018), the SPT’s role after a whistle-blower raised concerns was “very illuminating in terms of the culture and attitude towards safeguarding concerns displayed by the management of this facility”, according to the report by the National Independent Review Panel, which was completed in 2020. There are ongoing calls for the HSE to release the full report to inform learning and promote transparency in adult safeguarding.
Speaking to the media in December, senior HSE management and Government Ministers were categorical that incidents such as the Brandon case were unacceptable. HSE CEO Mr Paul Reid said the Executive had introduced “dedicated safeguarding resources and procedures”.
SPT CHO 7
On 21 September 2021, the Principal Social Worker at the SPT in Dublin South, Kildare and West Wicklow (DSKWW) emailed her line manager after a meeting that morning, where it was explained that the required resourcing for the team was not available.
The SPT in DSKWW, also known as Community Healthcare Organisation (CHO) 7, receives around 20 per cent of national safeguarding referrals but its funding allocations have never reflected this workload.
Since 2016, records show successive principal social workers at the team appealed to management for the resourcing necessary to respond in a timely manner to safeguarding concerns – through communications, business cases and risk assessments.
“The safeguarding team has not been adequately staffed since it started,” read a risk assessment dated September 2016, which identified vulnerabilities such as increased risk of abuse of vulnerable adults, and exhausted and stressed staff.
An internal risk register from November 2021, also released under Freedom of Information (FoI) law, referred to “risk of harm” to adults at risk of abuse “due to inadequate number of safeguarding social workers per CHO population” to provide timely access to appropriately trained professionals to case manage, investigate allegations, and deliver training, etc.
In the intervening years, the problem had spiralled. In late 2020, 1,812 alleged abuse cases submitted by services had not been examined, with some dating to June 2019. The team also had 1,626 safeguarding plans, dating to 2016, that it had been unable to examine, as reported by the Medical Independent (MI) last year.
During the Covid-19 pandemic there were increasing community referrals and greater complexity of cases. The caseload included domestic violence, ongoing grooming and sexual exploitation of younger vulnerable adults, ‘cuckooing during cocooning’, and financial abuse. Two experienced staff were also involved in a safeguarding investigation in a facility in DSKWW.
However, despite the serious and sensitive nature of this work, and HSE plans to roll-out a new policy across divisions, internal communications from DSKWW show its Chief Officer Ms Ann O’Shea described the national investment in adult safeguarding in 2021 as “minute”.
By autumn 2021, amid ongoing resourcing challenges and considerable extra work and risks posed by the cyberattack, the SPT had made significant inroads on addressing the unreviewed cases. Some agency resourcing had been provided to assist with the backlog, but this arrangement was tenuous for several reasons, including the competitive employment market for social workers.
In September 2021, the backlog of preliminary screenings stood at around 600, dating to January 2020, and 1,636 safeguarding plans dating to 2016. However, on 21 September, the Principal Social Worker, Ms Celine O’Connor, also reported to management a “newer backlog” of 30 abuse concerns and 15 safeguarding plans dating to 8 September due to under staffing.
In an email to Dr Sinead Reynolds (PhD), DSKWW’s Head of Service for Quality, Safety and Service Improvement (QSSI), Ms O’Connor stated that she was “disappointed that no permanent resources can be found at this time” given the backlog dated to 2018 and “each time staffing reduces and agency resource is withdrawn we begin to grow the backlog again”.
While “grateful for the acknowledgement that we require more”, the lack of funding for permanent posts “has been very demoralising for the team”, according to records obtained under FoI law.
There was no waiting list for community cases but due to the decreasing number of social workers, there were delays in providing intervention, reported Ms O’Connor, who gave an overview of staffing shortfalls and requirements, as well as the nature of recruitment and retention difficulties.
Community cases were remaining open for longer, there were gaps in getting interventions in place and people were being left at risk of abuse for longer. “It will also cause reputational damage to the HSE if [interventions in] abuse cases in community are being delayed and people are being harmed or die as a result,” outlined Ms O’Connor, who further noted the risks to running a service where agency staff outnumbered permanent staff. In her communications, Ms O’Connor also drew attention to the commitment of the social workers and administrative staff at the SPT.
Ms O’Connor and Dr Reynolds were in regular contact on SPT resourcing, the latter becoming line manager for the team in spring 2021 as part of changes in the governance structure for SPTs nationally.
On 24 September, attaching a draft business case, Dr Reynolds responded that “much of what you discuss in the email below is well known and accepted in terms of the overall resourcing of CHO7”.
Dr Reynolds continued: “As discussed at our meeting we can submit information to national community operations every year as part of the estimates process and when the letter of determination is received by the HSE we are told what our budgets will be for each area for the following year. Once this happens we are legally obliged to make the best use of the resources that we have. There are many areas where resources are limited and we are challenged accordingly in terms of service provision. This is common to many public services.”
Dr Reynolds did not believe it was useful to “keep going over this in written correspondence as it takes time and distracts from the job at hand”. Her email indicated she was attempting to build a case for durable resourcing.
“It is disappointing that safeguarding people at risk of abuse is not seen as a priority area for the HSE to fund given its legal obligation to protect the health and welfare of the public”
Ms O’Connor agreed that “having to repeatedly flag the gaps” was a waste of time. However, “when a serious incident does occur I won’t have it said that I haven’t actively tried to get resources for the team and the clients we assist”.
The Principal Social Worker, who acknowledged Dr Reynolds’ assistance, added: “It is disappointing that safeguarding people at risk of abuse is not seen as a priority area for the HSE to fund given its legal obligation to protect the health and welfare of the public. The team here will continue to use the resources we have in the most efficient manner and will continue to highlight when we can’t meet the need.”
In late January, a DSKWW spokesperson informed MI the SPT had completed the “historic backlog” of preliminary screenings. “Currently the majority of new preliminary screenings are being reviewed on the day that they are received. All current preliminary screenings are being reviewed within a week,” they outlined.
“There is a historic backlog of 1,784 safeguarding plans which go back as far as April 2016. These are plans put in place by services following preliminary screenings which have been viewed by the safeguarding team.”
Staffing levels “do impact the length of time that cases are open in the community” and priority is given to cases where the individual is at immediate risk of harm.
In 2021 additional funding was provided to the CHO SPT for two social work team leader posts, a professionally qualified social worker post and a grade VII (business manager) post (although internal correspondence showed the Principal Social Worker stated that these social worker posts would not nearly be enough for the workload requirements).
The CHO also provided “specified purpose funding for agency posts where this was achievable within funding limits available”.
DSKWW senior management had raised concern with senior management in Community Operations and the HSE National Safeguarding Office (NSO) in regard to SPT staffing.
Two “safeguarding risks” have recently been escalated from the QSSI risk register to the Chief Officer’s risk register, stated the spokesperson.
According to the HSE, operational plans for 2022 were being finalised, and to date staffing in SPTs has not been adjusted to population or demand.
“The HSE is working at corporate and regional management levels to address the ongoing challenges operating the safeguarding policy in CHO 7… No other CHO has reported a backlog, nor have any other backlogs been identified by the NSO.”
Meanwhile, the Department of Health referred to Budget 2022 measures including €600,000 to employ 18 additional social workers “to provide safeguarding supports” in nursing homes. These posts in new community support teams “will enhance” the nine SPTs.
A revised HSE adult safeguarding policy has remained in draft since 2019. There is widespread support for replacement of the 2014 policy, which is limited to social care and has been inconsistently interpreted and implemented. However, the proposed new policy has raised a number of concerns.
Last May, Head of Quality and Patient Safety in HSE Community Operations, Mr JP Nolan, provided an “update” on policy implementation to National Director of Community Operations, Ms Yvonne O’Neill.
Based on current capacity, Mr Nolan did not foresee the revised policy becoming operational before 2022 and this would depend on the next national service plan “supporting a feasible operating model”. His email also referred to lack of investment in the SPTs in 2021 and an intention to introduce nursing safeguarding roles to the CHOs, a proposal that has perplexed some social workers due to existing deficits in safeguarding and the competencies involved.
According to his email, Mr Nolan had been engaging with the NSO, CHOs, the Department of Health and health sector unions, and found this area of practice to be “divisive”. In some respects, outside of the NSO and the SPTs, safeguarding was “poorly understood in comparison to other jurisdictions where I have worked”, added Mr Nolan, a former nurse with a broad range of clinical and advisory experience in the nursing profession.
Defining pathways under the new policy would require “comprehensive engagement” with stakeholders. “I have already indicated to these parties that we will not choose between a specialist team and an ‘in-service’ model – we need both. That in turn at CHO level would probably look like the SPTs continuing their specialist services but also a safeguarding investment in either the five current care groups”- believed to be a reference to the main HSE care divisions – “or the future 96 CHNs” – a reference to the community healthcare networks planned under Sláintecare reforms.
In his note, Mr Nolan observed that the Department of Health was also developing an adult safeguarding policy which could potentially require technical amendments to the HSE policy.
A part of the email was redacted and it resumed by stating there were some matters that in the interests of safety could not be conceded – “for example the position put to us that only social workers can undertake safeguarding work. I have reiterated our acceptance, as per previous agreements, that social work are the lead profession for safeguarding but it would be untenable for us to accept that no other profession has a role to play”.
All of the above was happening “against a narrative that views the HSE as the lead agency for the protection of adults at risk of abuse. While we should be always focused on what we can and should do, there are limits to our powers to act and roles for local government, justice, finance and others that we can’t perform for them.”
Mr Nolan expressed hope that the policy and legislative landscape may evolve to “provide some clarity” on these issues.
Adult safeguarding is regarded as complex and labour intensive, with casework involving many considerations including the rights of clients, right to self-determination and legal processes. In this context, many social workers view the proposed new policy as unworkable and not fit for purpose.
The policy introduces new roles of ‘safeguarding manager’ and ‘safeguarding coordinator’ but lacks clarity on who would assume such roles in clinical settings. It suggests a more distanced role for the SPTs.
A 2020 paper on adult safeguarding by the Irish Association of Social Workers (IASW) stated: “While the IASW agrees that it is essential that all health and social care professionals can identify risk and abuse, it is also vital that adults experiencing abuse and harm have direct access to the expertise of frontline safeguarding social work professionals.”
The IASW paper said safeguarding social workers had expert knowledge in the patterns and complex dynamics of abusive behaviours, including domestic violence, institutional abuse, coercive control, perpetrator grooming of professionals, and barriers to safety for those experiencing abuse and neglect. Safeguarding social workers were experts in co-working with An Garda Síochana, financial institutions and within the complexities of the Irish legal system.
On the proposed HSE policy, Ms Chris Cully, Assistant General Secretary at Forsa, told MI it was important the role of social worker was “not diluted and becomes anybody’s job”.
Ms Cully added: “We want to make sure the right professionals are involved at the right stages. Safeguarding is everybody’s responsibility, but there are certain responsibilities that should remain the domain of social workers from a statutory, advocacy point of view.”
Subject to negotiations, there could be more safeguarding case co-working between social workers in different settings, but also between social workers and other healthcare professionals, in the future. Ms Cully said the union needs to protect the terms and conditions of members and ensure there is not a blurring of lines between professions. She added: “I am not opposed to multidisciplinary team working as long as everyone understands their role within that MDT.”
MI understands some social workers in primary care are currently not taking on any safeguarding casework. The lack of adult safeguarding legislation and a health sector-wide policy, inconsistent implementation of the current policy, unclear referral thresholds in the safeguarding process, under-resourcing, and out of date job descriptions, are contributing factors. There is no Forsa instruction to primary care social workers that they should not take on safeguarding casework, the union confirmed.
The HSE’s spokesperson commented: “The current and only safeguarding policy in operation is the 2014 policy and it is expected this will remain extant for the foreseeable future. Work will continue throughout 2022 on designing a future operating model for safeguarding in line with the wider programme of health service reform.”
On introducing the new role of safeguarding nurse, the spokesperson said: “While social work is, and will continue to be, the lead profession with respect to safeguarding, it is critical they are not the only discipline involved. Nurses are one of the largest professional groups in health and social care, and the majority of designated officers for safeguarding are nurses.”
“It is the intention of the HSE to introduce a small cohort of nurses working to support the implementation of the HSE safeguarding policy, specifically in the context of holistic nursing practice. Consultation with stakeholders is ongoing in this regard. “
DoH policy and legislation
As the HSE has been developing its revised policy and implementation plan (which is unlikely to be implemented in its current form) a parallel process has been ongoing at the Department of Health.
The Department is planning to publish its draft policy for consultation. In addition, a Health (Adult Safeguarding) Bill is included in the Government’s spring legislative programme, although not in the ‘priority legislation’ section (also listed is the Protection of Liberty Safeguards Bill).
However, organisations including HIQA and Safeguarding Ireland (a HSE-funded awareness-raising body) have emphasised the need for a whole-of-society legislative framework.
Ms Patricia Rickard-Clarke, Chair of Safeguarding Ireland, said that confining adult safeguarding legislation to health and social care did not go far enough. She noted that issues such as coercive control and financial abuse involved a range of sectors of society.
There was a need for a multidisciplinary “overarching authority which is independent of all service providers, who would have the statutory function to carry out investigations in certain cases”.
Safeguarding Ireland is working on a research paper, which it hopes to publish in March, looking at challenges and best practice considerations in relation to a legal framework for adult safeguarding. The Law Reform Commission is due to publish a regulatory framework for adult safeguarding in the summer.
The long-awaited launch of the decision support service, which is due to open in mid-2022, will be an important advancement in regard to safeguarding, noted Ms Rickard-Clarke. Established under the Assisted Decision-Making (Capacity) Act 2015, the service will promote the rights and interests of adults who may require support to make decisions about their personal welfare, property, and affairs. Other legislative requirements include regulations under data protection law to fully address information sharing in the public interest, added Ms Rickard-Clarke.
In relation to the HSE, Ms Rickard-Clarke said its internal safeguarding capabilities would need to be enhanced, in tandem with the development of any independent investigative authority.
In the wake of scandals such as the Brandon case, MI asked about the scale of cultural change necessary in the HSE. She said: “It is a very large organisation and you find very good processes there on the one hand, and in other areas not so good. Remember, we are still working on a policy, we have no underlying legislation. So we need adult safeguarding legislation with very clear standards, very clear regulation, and very clear reporting avenues and we don’t have any of that. We need that framework to be put in place.”
There is a lack of mandatory modules relating to adult safeguarding for doctors in training. Higher specialist trainees in geriatric medicine are required to undertake a module titled ‘Respecting autonomy and safeguarding the rights of older people’. It aims to help doctors “recognise the warning signs of elder abuse” and know how to report suspected cases.
However, this module is not a requirement for other trainees in RCPI nor are there any specific adult safeguarding modules.
A RCPI spokesperson said adult safeguarding issues are often raised on trainee study days and within the College’s ethics courses.
RCSI “offers” a module on adult safeguarding and the “rights of vulnerable patients” within its Human Factors and Patient Safety programme, which is mandatory for all trainees in surgery and emergency medicine.
“We have also included a mandatory module in active bystander intervention. There is also a section on safeguarding vulnerable adults on our trainee portal.”
The College of Psychiatrists said: “We do include the assessment of risk of abuse to ‘vulnerable’ adults in our training curriculum, supervisors teach and assess this with trainees and this subject may be examined in membership examinations.”
Feedback from individual psychiatrists indicated safeguarding was regarded as a social work function. However, lack of out of hours social work support was raised. An example was also provided of a safeguarding social worker believing a psychiatry MDT would manage a safeguarding concern as it was assumed this was preferred.
Another psychiatrist, Dr Patricia Walsh, emphasised to the Medical Independent (MI) that adult mental health services required “a 21st century infrastructure of electronic patient records” to facilitate communication with agencies like Tusla, the gardai, adult safeguarding, probation, etc, as well as promote safer prescribing practice and care. Dr Walsh said there needed to be clearer structures and processes across health and social care for management of adult safeguarding.
Adult safeguarding concerns in acute settings are usually referred to medical social workers, although some hospitals do not have a social worker or minimal staffing.
Ms Amanda Casey of the Irish Association of Social Workers, who is Principal Medical Social Worker at the Mater Hospital in Dublin, told MI referrals would often arise following presentations to the emergency department. Such referrals would usually come from nursing or medical staff.
An example would be a person admitted from a nursing home where there are signs of poor care or neglect. Financial abuse of the patient has also arisen during the application process for long-term care.
In Ms Casey’s experience, the medical social worker would take the lead role in doing the initial screen and safeguarding plan and link with other relevant services. There is a “reasonably well resourced” team at the Mater with the ability to assess and manage safeguarding cases. The medical social work team would often seek the advice of the relevant safeguarding and protection team (SPT) in community operations and refer the case onwards to them.
“We can make a referral to the SPT but obviously one of the frustrating things is they don’t have an automatic right of entry to private nursing homes. Equally we can send concerns to HIQA, but they don’t investigate individual complaints,” noted Ms Casey.
There is a need for adult safeguarding training requirements for hospital-based healthcare professionals, confirmed Ms Casey. “We are reliant on people having the wherewithal to notice it and do something about it,” she said. “That is contingent on staff having the time to notice these things and having the time to ask those questions, which is not always possible in that sort of an environment.”
Ms Casey said certain forms of abuse, such as coercive control, are “less seen and less obvious” particularly without training.
The core problem is the absence of adult safeguarding legislation, she added. “That legislation would need to involve consideration of things like mandatory reporting, of access to private nursing homes [etc]…”
Ms Casey said all health and social care professionals had a significant role in adult safeguarding. However, “it’s important that [the lead role] lies with a profession such as social work because of our training”.
“There is a mantra that ‘adult safeguarding is everyone’s responsibility’ and I always have a worry that by saying it is everyone’s responsibility, it becomes no-one’s responsibility…There does need to be a lead profession who has a specific skillset and specific responsibility to manage these concerns, and coordinate what can often be incredibly complex situations … it makes sense that social work would continue to take a lead role in that.”
A HSE spokesperson said an adult safeguarding training programme on the HSELanD (Health Service‘s e-Learning and development) platform was available to all health and social care workers including in voluntary hospitals.
“There is a requirement that all personnel in HSE and HSE-funded services across both disability and older persons sectors undertake the online HSELanD adult safeguarding training programme once every three years.”
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